Wellness Questionnaire

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0

Name
0

Age
0

Gender
Male

Female

Other (Please specify)
0

What is your job category?
Student

Administrative

Academic

Professional - Self-employed

Professional - Corporate

Other (Please specify)
0

What is your annual income?
Less than $25,000

Between $25,000 and $50,000

Between $50,001 and $100,000

More than $100,000
0

Are you especially concerned for your health?

Not at all

Definitely

Not at all

Definitely

1 Not at all

2

3

4

5 Definitely
0

On average, how often do you visit a general practitioner in a month?
Never

Once

Twice

Three to five times

More than five times
0

Which, if any, of these ailments do you suffer from? Choose all that apply.
High blood pressure

High cholesterol

Heart condition

Diabetes

Asthma

Overweight

None of the above

Other (Please specify)
0

Which, if any of these, ailments concern you (whether due to family history, lifestyle, previous experience, or other)? Choose all that apply.
Heart disease

Cancer

Stroke

Auto-immune disease

Osteoporosis

Depression

None of the above

Other (Please specify)
0

On average, how long do you sleep?
Less than 4 hours

4 - 6 hours

7 - 10 hours

More than 10 hours
0

Typically, how often do you workout?
Never

Once a week

2 - 3 times a week

4 - 6 times a week

Everyday
0

How long does your typical workout last?
Less than 10 minutes

10 - 30 minutes

31 - 60 minutes

More than 60 minutes
0

How active is your lifestyle?
Sedentary (desk job)

Slightly active (desk job accompanied by five-minute walks)

Moderately active (work demands travel)

Highly active (work demands heavy lifting and movement)
0

Do you smoke?
Yes

No
0

How often do you smoke?
Rarely

1 cigarette a day

2 - 4 cigarettes a day

5 - 10 cigarettes a day

More than 10 cigarettes a day
0

Do you drink?
Yes

No
0

How often do you drink?
Less than once a week

Once a week

2 - 4 times a week

5 - 7 times a week

More than 7 times a week
0

Rate how much emotional support you feel you have from your friends/relative.

Not at all

A lot

Not at all

A lot

1 Not at all

2

3

4

5 A lot
0

How often do you attend social gatherings (club meetings, family gatherings, and others)?
Never

Less than once a month

At least once a month

2 - 4 times a month

More than 4 times a month
0

How often do you feel lonely?
Never

Rarely

Sometimes

Often

Always
0

How often do you feel stressed in a typical week?
Never

Rarely

Sometimes

Often

Always
0

How do you manage your stress?
Exercise

Eating

Deep breathing

Meditating

Reading

Listening to music

Walking or hiking

Playing a sport

Other (Please specify)
0

How healthy would you rate yourself to be?

Poor

Excellent

Poor

Excellent

1 Poor

2

3

4

5 Excellent

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0

Name
0

Age
0

Gender
Male

Female

Other (Please specify)
0

What is your job category?
Student

Administrative

Academic

Professional - Self-employed

Professional - Corporate

Other (Please specify)
0

What is your annual income?
Less than $25,000

Between $25,000 and $50,000

Between $50,001 and $100,000

More than $100,000
0

Are you especially concerned for your health?

Not at all

Definitely

Not at all

Definitely

1 Not at all

2

3

4

5 Definitely
0

On average, how often do you visit a general practitioner in a month?
Never

Once

Twice

Three to five times

More than five times
0

Which, if any, of these ailments do you suffer from? Choose all that apply.
High blood pressure

High cholesterol

Heart condition

Diabetes

Asthma

Overweight

None of the above

Other (Please specify)
0

Which, if any of these, ailments concern you (whether due to family history, lifestyle, previous experience, or other)? Choose all that apply.
Heart disease

Cancer

Stroke

Auto-immune disease

Osteoporosis

Depression

None of the above

Other (Please specify)
0

On average, how long do you sleep?
Less than 4 hours

4 - 6 hours

7 - 10 hours

More than 10 hours
0

Typically, how often do you workout?
Never

Once a week

2 - 3 times a week

4 - 6 times a week

Everyday
0

How long does your typical workout last?
Less than 10 minutes

10 - 30 minutes

31 - 60 minutes

More than 60 minutes
0

How active is your lifestyle?
Sedentary (desk job)

Slightly active (desk job accompanied by five-minute walks)

Moderately active (work demands travel)

Highly active (work demands heavy lifting and movement)
0

Do you smoke?
Yes

No
0

How often do you smoke?
Rarely

1 cigarette a day

2 - 4 cigarettes a day

5 - 10 cigarettes a day

More than 10 cigarettes a day
0

Do you drink?
Yes

No
0

How often do you drink?
Less than once a week

Once a week

2 - 4 times a week

5 - 7 times a week

More than 7 times a week
0

Rate how much emotional support you feel you have from your friends/relative.

Not at all

A lot

Not at all

A lot

1 Not at all

2

3

4

5 A lot
0

How often do you attend social gatherings (club meetings, family gatherings, and others)?
Never

Less than once a month

At least once a month

2 - 4 times a month

More than 4 times a month
0

How often do you feel lonely?
Never

Rarely

Sometimes

Often

Always
0

How often do you feel stressed in a typical week?
Never

Rarely

Sometimes

Often

Always
0

How do you manage your stress?
Exercise

Eating

Deep breathing

Meditating

Reading

Listening to music

Walking or hiking

Playing a sport

Other (Please specify)
0

How healthy would you rate yourself to be?

Poor

Excellent

Poor

Excellent

1 Poor

2

3

4

5 Excellent